Understanding Long-term Requirements in Pulmonary Rehabilitation for COPD: Insights from Interviews with Respiratory Care Professionals

doi:10.21203/rs.3.rs-3152405/v1

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Understanding Long-term Requirements in Pulmonary Rehabilitation for COPD: Insights from Interviews with Respiratory Care Professionals

https://doi.org/10.21203/rs.3.rs-3152405/v1

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Chronic obstructive pulmonary disease (COPD) is characterized by persistent obstruction to airflow through the lungs and long-term respiratory symptoms. Apart from dyspnea, a critical characteristic of patients with COPD is an impaired capacity to exercise, which limits their ability to participate in daily activities and severely impacts their quality of life. To provide a precise and effective exercise prescription, it is necessary to translate exercise science into evidence-based recommendations for pulmonary rehabilitation (PR).

This study aims to enhance our understanding of the continuous requirements for long-term PR in COPD patients. To achieve this, a series of semi-structured investigations will be conducted, focusing on three key aspects: exploring the essential tasks and conditions for implementing PR, identifying the specific requirements for assistive devices, and examining the health management practices for patients after hospital discharge. The interviews were carried out with a convenience sample of 24 respiratory care professionals who possess an average of 17 years of relevant clinical work experience and are actively involved in providing PR services to COPD patients.

Interviews were transcribed verbatim, and analysis was undertaken to identify the following themes: (1) Necessary Conditions for Clinical Pulmonary Rehabilitation ; (2) The Need for Assistive Devices in Pulmonary Rehabilitation ; and (3) Post-Discharge Care for Patients with Chronic Lung Disease.

Our findings indicate that the implementation of exercise training to enhance the exercise capacity of COPD patients is a complex process. Barriers associated with respiratory care professionals (RCPs) contribute to the challenges in effectively implementing exercise training programs. These barriers emphasize the importance of precise measurement and monitoring of physiological parameters. Furthermore, it is crucial to consider individual differences, limitations in workplaces and medical resources, and the effective utilization of technology for continuous monitoring of patient recovery.

chronic obstructive pulmonary disease (COPD)

exercise prescription

pulmonary rehabilitation(PR)

physician-related barriers

physiological monitoring

Chronic obstructive pulmonary disease (COPD) is a major public health problem and is the third-leading cause of morbidity and mortality by disease worldwide[1–3]. More than 328 million people were diagnosed with COPD in 2019[4, 5], a disease that is caused mainly by tobacco smoking and air pollution. Physical activity is significantly correlated with lung function[6–9]. Regular exercise is critical for patients with COPD [10–12]; however, the most predominant symptom of COPD is dyspnea, which is associated with a chronic cough, exacerbations of COPD, and reduced exercise capacity[13–15].

Lower levels of physical activity are often culminating in reduced quality of life[16–19] and with an elevated risk of premature death. Thus, increasing the physical activity levels of patients with COPD and understanding their determinants, such as the recommended level and intensity of exercise, are crucial issues.

Pulmonary rehabilitation (PR) through exercise training is a well-established intervention for COPD patients[19–21]. Compared with other therapies, PR is a low-cost and high-impact intervention that broadly comprises diagnosis, training, and evaluation, all of which slow the progression of the disease[22–24]. Furthermore, COPD is clinically a complex disease; therefore, general guidelines may not be suitable for all patients. For example clinical research has indicated that individual COPD patients have different medical needs and require different treatments[25, 26]. Physicians who develop exercise prescriptions and supervise exercise training for COPD patients should consider patient diversity, which includes disease variability and severity, as well as the interpretation and use of the diverse components of PR programs[27].

Each physician sets different exercise prescriptions for COPD patients, and the vast majority of exercise prescriptions on the market are only suitable for patients who are in a more stable and healthy condition, making it difficult to achieve precision. In addition, most COPD patients do not like to exercise due to physical discomfort or respiratory difficulties, and when the exercise prescription exceeds their ability, patients are prone to rejection and even life-threatening situations[28–30]. It is essential to establish an objective and scientifically based respiratory rehabilitation/exercise prescription system. Therefore, this study aims to explore respiratory care professionals' perspectives on the needs, viewpoints, and opinions of COPD patients in clinical practice, as well as to understand patients' acceptance of respiratory rehabilitation, their ability to comply with respiratory rehabilitation/exercise prescriptions, and other related issues. By incorporating the viewpoints of respiratory care professionals, it will be helpful to design an intelligent respiratory rehabilitation system to break through the difficulties in rehabilitation medicine and improve the effectiveness of medical prescriptions.

This study employed a qualitative research design, utilizing semi-structured interviews with open-ended questions, to gain insights into the perspectives of clinical professionals regarding PR.

Participants

Twenty-four respiratory care professionals (14 females, 10 males) aged 35 to 65 years were recruited for this study. They represented various professions in public and private hospitals, as well as community health centers (refer to Table 2). Prior to their participation, all participants provided informed consent by signing a consent form. No participants withdrew from the study during the research period.

The current treatment approach for COPD primarily centers around PR and pharmacological interventions. Within the scope of rehabilitation methods, lower limb training has received considerable attention due to its pronounced therapeutic effects on COPD. Hence, the aim of this study was to gather and utilize the clinical experiences of the interviewees to contribute to the development of lower limb strength training interventions for COPD patients. A total of 24 RCPs were recruited via email or phone and subsequently invited to participate in a survey. This study received approval from the Research Ethics Committee for Human Subject Protection of Chang Gung Medical Foundation (IRB NO. 202200070B0).

Data collection

The interviews were conducted via telephone in response to the COVID-19 pandemic. Each interview had a duration of approximately 60 to 90 minutes and was conducted by the author, a clinical researcher and assistant professor affiliated with Chang Gung Medical Foundation. The initial version of the interview topic guide was developed based on relevant literature and underwent a pilot test[43, 44]. The pilot test results were discussed with respiratory care professionals, leading to collaborative refinement and the creation of the final version. Prior to the interviews, the interviewees received a questionnaire outline. During the interviews, a voice recorder was utilized to capture the conversations, which were then transcribed verbatim. To ensure accuracy, the transcriptions were validated by an additional reviewers who cross-checked the recordings against the transcribed contents.

Data analysis

The interview transcripts were subjected to thematic analysis using NVivo 12 software. Two independent reviewers conducted a thorough line-by-line analysis and manually coded the data. Themes and subthemes were identified and organized based on the assigned codes (Table 1). The interpretations were then compiled as summarized data, ensuring the confidentiality of the interviewees. To ensure the robustness of the analysis, the primary author carefully reviewed each transcript, applying distinct labels for coding and deriving themes and subthemes. The coding process was validated by two respiratory care professionals. This meticulous approach aimed to ensure the accuracy and credibility of the study's findings.

Table 1

Interview topic guide
Theme	Sub-theme
1. Necessary Conditions for Clinical Pulmonary Rehabilitation (PR)	1.1 Exercise Frequency in Pulmonary Rehabilitation: What is the Optimal Duration and Frequency for Patients?
	1.2 Considerations and Requirements for Pulmonary Rehabilitation Training Programs.
	1.3 Essential Monitoring Parameters During Pulmonary Rehabilitation.
	1.4 Common tools used in analyzing effect of exercise training on clinical outcomes in patients with COPD.
2. The Need for Assistive Devices in Pulmonary Rehabilitation (PR)	2.1 Equipment Utilized in Pulmonary Rehabilitation.
	2.2 Is the Use of Non-Invasive Ventilation (NIV) Necessary in Pulmonary Rehabilitation?
	2.3 Comparing Exercise Intensity Alone vs. Exercise Intensity Combined with Endurance Training.
3. Post-Discharge Care for Patients with Chronic Lung Disease	3.1 Care for Patients with Chronic Lung Disease After Hospital Discharge.
	3.2 Management and Monitoring of Exercise in COPD Patients After Hospital Discharge.
	3.3 Exercise Monitoring for COPD Patients After Hospital Discharge: Equipment, Methods, and Indicators

From April to November 2022, 24 respiratory care professionals with an average of over 17 years of medical experience in respiratory therapy, chest medicine, and/or pulmonary/cardiac rehabilitation were recruited and interviewed. Out of the 24 interviewees, 10 were working in Chang Gung Medical Foundation, a major metropolitan hospital service that provides inpatient and outpatient rehabilitation services. The other 10 participants were working in private practices in rural areas, and 4 were working in regional local hospitals (Table 2).

Table 2. Participants’ characteristics (n = 24)
Characteristic	Number of Participants
Gender
Male	10 (41.6%)
Female	14 (58.3%)
Age	49.8(35–65)
Years in practice	18(3-27.9)
Occupation
Respiratory physician	15 (62.5%)
chest medicine	3 (12.5%)
Pulmonary/Cardiac Rehabilitation physician	4 (16.7%)
Physiotherapist	2 (8.3%)
Type(s) of hospital
Metropolitan hospital (private sector)	10 (41.6%)
Rural areas (public sector)	10 (41.6%)
Regional local hospitals	4 (16.7%)
Number of patients with COPD seen/week	25 (5–30)

This study found that " Clinical Needs in Pulmonary Rehabilitation" was the main theme, which covered three domains: (1) Necessary Conditions for Clinical Pulmonary Rehabilitation; (2) The Need for Assistive Devices in Pulmonary Rehabilitation; and (3) Concerns and Challenges After Hospital Discharge. In these three domains, RCPs acknowledged that patient differences, provider backgrounds, and health system factors could affect the quality and acceptance of healthcare. The majority of participants believed that the setting of medical prescriptions would directly impact the effectiveness of patients' recovery. Tables 3–5 summarize the resulting sub-themes and illustrative quotes.

Necessary Conditions for Clinical Pulmonary Rehabilitation

Interviewees highlighted the importance of a training program that consists of different variables (Table 3), such as intensity, duration, and exercise frequency. A cardiopulmonary exercise test (CPET) is an effective way of diagnosing and evaluating a patient's functional capacity. This assists physicians in developing an individualized therapy prescription and helps patients to obtain the maximum benefit from exercising. However, it should be noted that more than one-third of the respondents mentioned that not all hospitals or treatment centers possess CPET measuring instruments. Therefore, considering CPET as the sole criterion for prescribing medical treatment may pose challenges.

Several interviewees expressed that while exercise cannot reverse lung damage, regular exercise can enhance a patient's physical endurance, strengthen respiratory muscles, and improve respiratory function in COPD patients. In clinical practice, patients are typically advised to engage in 30 minutes of moderate exercise daily, ideally performed three times a week, totaling 24 sessions, and notable improvements are typically observed within a period of approximately 2 months. However, only a minority of patients are capable of adhering to the prescribed exercise regimen due to experiencing breathlessness during exertion. These individuals often demonstrate limited interest in the content of rehabilitation programs and frequently lack confidence in the recovery process.

Over half of the interviewees indicated that the majority of patients lack knowledge about what constitutes moderate exercise and have no concept of the types of exercises they should engage in. Consequently, they are unable to effectively manage their exercise regimen. Furthermore, the interviewed participants in this study mentioned that while CPET is currently considered a more precise clinical measurement instrument, for rural areas, local hospitals, and medical institutions without such equipment, the 6-minute walking test (6MWT), the Borg Scale, the Modified Medical Research Council (mMRC) Dyspnea Scale, and the St George's Respiratory Questionnaire (SGRQ) are commonly utilized to assess a patient's respiratory capacity. In addition to physiological parameters, RCPs also assess a patient's social life and mental health such as the COPD Assessment Test (CAT), as many COPD patients concurrently experience anxiety and depression, which are comorbid mental health concerns in COPD.

Table 3

Necessary Conditions for Clinical Pulmonary Rehabilitation
Subtheme	Quotes example
1.1Exercise Frequency in Pulmonary Rehabilitation: What is the Optimal Duration and Frequency for Patients?	“Different exercise rehabilitation programs are required to treat different stages of COPD (mild, moderate, severe, and very severe). From a chest physician's point of view, patients need to train for 30–35 minutes per day which includes a 5-minute warm-up and 5-minute cooldown and three to five times per week to gain maximum benefits.” (Interviewees 12, Respiratory physician, female) “In terms of effectiveness, notable improvements in respiratory function can be seen after 24 sessions.” (Interviewees 16, Chest medicine, male)
1.2Considerations and Requirements for Pulmonary Rehabilitation Training Programs.	“Before undergoing an exercise rehabilitation program, a series of cardiopulmonary function tests (CPET)are conducted. The results of these tests are used to design the perfect exercise prescription. (Interviewees 20 Pulmonary/Cardiac Rehabilitation physician, female) “The general principles of exercise prescription design are based on training frequency, intensity, time, and type (FITT). ”(Interviewees 19 Pulmonary/Cardiac Rehabilitation physician, female)
1.3Essential Monitoring Parameters During Pulmonary Rehabilitation.	“Identifying the stress that a patient can withstand is very subjective, the CPET can identify the mechanisms limiting exercise tolerance and determine the maximum heart rate to set physical fitness goals.” (Interviewees 3&5, Respiratory physician, female) “Monitoring training load to understand fatigue in patients with COPD” (Interviewees 7, Respiratory physician, female)
1.4Common tools used in analyzing effect of exercise training on clinical outcomes in patients with COPD.	“CPET is often conducted alongside data analysis with pre-test and post-test measurements of changes in patients' vital signs during exercise. The 6MWT and the Borg Scale are common to compare changes in performance capacity and measuring an individual's breathlessness during physical exercise.” (Interviewees 23, Physiotherapist, female) “We also use the COPD assessment test (CAT) to measure the impact of COPD on a patient's life and assess how this changes over time, which helps RCPs get more information about the patient's physical, mental, and social needs.” (Interviewees 9, Respiratory physician, male)

The Need for Assistive Devices in Pulmonary Rehabilitation

Regardless of whether it is urban, rural, or regional hospitals, different desires and needs arise during the implementation of COPD patient rehabilitation treatments. In this study, many participants expressed a preference for employing simple methods in clinical practice. While advancements in technological techniques have undoubtedly enhanced the convenience of numerous daily activities, high-tech methods may not necessarily constitute the optimal solution in the medical domain (Table 4).

One-third of the interviewees expressed that combining non-invasive ventilation during respiratory rehabilitation can extend patients' exercise duration and lead to better outcomes in terms of muscle strength training. The increase in training duration and exercise intensity contributes to the improvement of exercise capacity in COPD patients, thereby delaying physical and cognitive decline. However, the subjects of cardiopulmonary rehabilitation are patients with impaired cardiopulmonary function, which inherently poses higher risks. Without appropriate facilities (rehabilitation equipment), professional personnel, and dedicated settings, the use of non-invasive equipment for respiratory rehabilitation at home is currently not feasible.

Hence, the design of exercise prescription needs to consider individual differences and recognize the impact of intensity and duration on patients. Therefore, personalized design is necessary as appropriate exercise benefits patients' health, while inappropriate exercise may impose physical burden and life-threatening risks on individuals. Additionally, some interviewees have mentioned the difficulties associated with implementing home-based respiratory rehabilitation and monitoring due to equipment and spatial constraints. Leveraging the characteristics of telemedicine, such as remote consultation, monitoring, and alerts, may achieve optimal medical efficacy.

Table 4

The Need for Assistive Devices in Pulmonary Rehabilitation
Subtheme	Quotes example
2.1Equipment Utilized in Pulmonary Rehabilitation.	“Although the global development trend tends towards high-tech, this does not mean that we should rely on new devices in clinical practice. The three-ball breathing trainer is the most common device for inspiratory muscle training, because it is simple and convenient.” (Interviewees 17 Chest medicine, male)
2.2Is the Use of Non-Invasive Ventilation (NIV) Necessary in Pulmonary Rehabilitation?	“Clinical evidence shows that patients who use non-invasive ventilation or high-flow nasal cannula during exercise achieve higher rehabilitation performance. However, all these devices are heavy and bulky and have many wires, and physicians are also needed to control the volume of oxygen.” (Interviewees 1, Respiratory physician, female) “Using oxygen must always be used carefully, because which might worsen the patient’s condition and cause rupturing of alveoli.” (Interviewees 16 Chest medicine, male)
2.3 Comparing Exercise Intensity Alone vs. Exercise Intensity Combined with Endurance Training.	“Undoubtedly, incorporating individual differences and combining muscle strength training with endurance exercise training is more effective in improving athletic performance than providing a single training modality.” (Interviewees 5, Respiratory physician, female)

Post-Discharge Care for Patients with Chronic Lung Disease

Most of the respondents indicated that they were discharged from the hospital within 30 days of admission due to limited liability insurance. In light of this, RCPs anticipate using telehealth as a means to monitor their patients in the future.

The participants unanimously expressed the expectation that patients with COPD should engage in regular exercise following their discharge from the hospital, as it helps mitigate the risk of developing various long-term (chronic) conditions. It is crucial to select suitable equipment that enables patients to engage in at least 30 minutes of exercise daily. Furthermore, the utilization of digital technologies for monitoring patients' ongoing recovery is becoming increasingly prevalent (Table 5).

Table 5

Post-Discharge Care for Patients with Chronic Lung Disease
Subtheme	Quotes example
3.1 Concerns and Challenges After Hospital Discharge	“From a clinical perspective, for both inpatients and discharged patients, patient safety is always the priority.” (Interviewees 18 Chest medicine, female) “I wish we could continue monitoring a patients' vital signs, such as heartbeat, blood oxygen, and end-tidal CO². However, due to hardware limitations, it is difficult to measure end-tidal CO² at home.” (Interviewees 7, Respiratory physician, female)
3.2Management and Monitoring of Exercise in COPD Patients After Hospital Discharge.	“Discharged patients are always a major concern for us. It's hard to keep track of them once they go home, and we often see them again when their condition worsens and they end up back in the hospital.” (Interviewees 2, Respiratory physician, female)
3.3Exercise Monitoring for COPD Patients After Hospital Discharge: Equipment, Methods, and Indicators	“For safety purposes, I highly recommend choosing a type of stationary bicycle for exercise training and record their vital signs as well as upload data to a cloud, it will be useful and a big step forward in telemedicine.” (Interviewees 9, Respiratory physician, female) “Walking is a good simple form of exercise (especially for elderly people), for which an oximeter could be combined with the 6MWT to evaluate a patient’s recovery.” (Interviewees 13, Respiratory physician, female)

The study offered valuable insights into the requirements of utilizing technology for addressing the needs of discharged patients, including their care, monitoring, and assessment in home-based respiratory management, as well as the potential challenges associated with it.

The results of this qualitative study also reveal that clinical practice is aware of individual differences in exercise prescriptions. Physicians and physiotherapists tend to emphasize the importance of an optimized exercise prescription design over relying on high-tech assistance, our findings suggest that many patients do not follow instructions regarding exercise in the absence of support from physicians[31, 32]. Therefore, understanding the motivations for exercise is equally important for tracking long-term behavior in physical activity as well as for the continuous update and planning of exercise programs. There are, however, issues with remote monitoring, such as unpredictable environmental conditions, limitations in equipment, and the different living conditions of patients. This finding is consistent with recent research reporting that interventions need to consider both an individual’s exercise capacity and the different community settings where people live and that different methodologies should consider the utilization of current technologies[33–35].

Many participants reported that conducting a series of CPET as well as accessibility to sufficient and suitable monitoring equipment are imperative, particularly after patients are discharged from hospital. In terms of clinical practice, combining training of muscle strength and inspiratory muscle endurance is better than performing them in isolation. However, the perspectives of the RCPs in this study varied widely. For example, oxygen-producing machines are very heavy and expensive and require the expertise of RCPs to control the volume of oxygen; thus, this type of intervention must be implemented in hospitals. However, the challenge lies in the fact that not all hospitals are equipped with such facilities. Many rural and local hospitals need to seek alternative ways to proceed or modify their healthcare service models, such as implementing a hierarchical medical system. This approach involves a collaborative and specialized care system where patients are triaged and referred based on medical professional recommendations. Each level of healthcare institution assumes its respective responsibilities. By doing so, unnecessary medical expenses and treatment time can be avoided while minimizing the burden on patients, thereby allowing limited healthcare resources to be utilized more effectively. Furthermore, incorrect use of oxygen-producing machines can harm patients suffering from emphysema, which is associated with the lung conditions of COPD[36, 37].

As technology advances, telemedicine has become increasingly prevalent[38, 39], which has accelerated due to the spread of COVID-19. For safety purposes, a stationary bicycle is the best choice for a COPD patient discharged from hospital. Sensors within the bicycle can assess and record their physical activity levels and vital signs. To circumvent limited resources, patients can also utilize an oximeter combined with the 6MWT to evaluate recovery.

This is the first qualitative study exploring RCPs' experiences and perceptions of implementing PR and long-term care in COPD patients. The results of this study indicate that the current designs for exercise prescription are insufficient to drive improvements in practice. Future work should focus on optimizing the translation of evidence-based experience into clinical practice through the development of rehabilitation programs both during a patient’s stay in hospital and following discharge. Exercise prescription should be tailored to the challenges of an individual’s exercise capacity and workplace, including limitations in physical activity and medical resources. Finally, technology applications should be regularly reevaluated and refined to ensure the sustained recovery of patients.

There are limitations in this study that must be considered when interpreting our findings. To obtain information on their clinical experience in PR, we interviewed RCPs who mostly worked in large hospitals; However, there was a lack of careful consideration for the age and years of service differences among the interviewees, which could have resulted in variations in perspectives. The length of their service, work experience, and the environment in which they operate can influence their perspectives on the events and their level of expertise. A notable limitation from this study was that most interviewees recommended that COPD patients conduct CPET before participating in PR. However, the majority of RCPs serving in rural and regional healthcare facilities have mentioned the challenges they face in conducting CPET due to the high cost of equipment, which is not readily available in every hospital. These findings demonstrate that different work environments can lead to variations in service experience, resulting in disparities in the information they can provide. Furthermore, notable differences were observed among urban, rural, and different types of hospitals and future work should include a more balanced sample size of participants. The types of hospital service models for COPD patients also exhibit significant variations, and future work should consider the challenges of individual patients, including culture, resources, workplace, psychological factors, and living environment, all of which are barriers that might affect the willingness of patients to participate in physical activity. Finally, many different factors can influence changes in exercise behavior in patients with COPD, the reasons for which are diverse and complex (e.g., fear, incentives, disease progression, and social support), These reasons, which may stem from poor physical condition and result in exercise fear or inability to sustain physical activity, are likely associated with the patient's acceptance of healthcare services. Therefore, a better understanding of what influences individuals to commence and maintain exercise plans are equally important.

Clinical experience and evidence for the implementation of exercise training have a positive influence on PR interventions for individuals with COPD [40-42]. Therefore, supervised and monitored exercise training is recommended for patients with COPD at any stage, whether at home or recently being discharged from hospital. Importantly, exercise prescription is considered a key factor for efficacy.

The prescription of exercise primarily focuses on precisely measuring vital signs and using these physiological signals to arrange appropriate training tasks. The effective delivery of exercise prescription includes optimizing the translation of evidence-based experience into clinical practice, whether for inpatients or outpatients, and should consider from different perspectives the limitations of the workplace of patients and medical resources.

Effective utilization of technologies should also be adopted to monitor the sustained recovery of patients. Many interviewees suggested that patients with COPD conduct CPET, which could assist RCPs in providing more precise exercise prescriptions and increase the efficacy of rehabilitation. However, not all medical units can afford CPET equipment, especially remote medical units, which often lack medical resources. As a result, the service model and exercise prescription designs will be substantially different among patients with COPD living in urban and rural areas.

Due to the presence of variations, consideration of individual patient circumstances is essential when designing personalized rehabilitation plans and providing healthcare services. Factors such as the patient's residential area, lifestyle, and medical conditions can differ significantly, influencing their acceptance of medical interventions. This is particularly noteworthy for COPD patients, who exhibit inherent individual differences that require tailored treatment and care approaches. Furthermore, environmental factors, educational level, and age also influence the patient's acceptance and the effectiveness of healthcare services. Hence, this study emphasizes the significance of delivering patient-centered and optimized healthcare services as a key aspect of achieving personalized and precision medicine.

Data Availability

The data analyzed in this study are available from the corresponding author upon reasonable request.

Acknowledgements

We express our gratitude to the participants who generously contributed their time, experiences, and insights to this study. Additionally, we would like to extend our thanks to Ying-Huang Tsai and Su-Er Guo for their invaluable support in recruiting the participants.

Funding

This research was supported by National Science and Technology Council (NSTC) grant 111-222-E-182-02-MY2.

Availability of data and materials

The datasets analyzed during the current study are not publicly available to protect personal data of the participants, but are available from the corresponding author on reasonable request.

Author information

Department of Industrial Design, Chang Gung University, Taoyuan, Taiwan

Shih-Ying Chien

Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Alice May-Kuen Wong & Shih-Ying Chien

School of Public Health Division of Community Health Sciences, University of California Berkeley, 2121 Berkeley Way, Berkeley, CA, 94720, USA.

Winston Tseng

Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Han-Chung Hu &Hsiu-Ying Cho

Department of Respiratory Therapy, Lin-Kou Chang Gung Memorial Hospital, Taoyuan, Taiwan

Han-Chung Hu

Author Contributions

S.Y. Chien was involved in the study design, conducted the interviews, collected and analyzed the data, and drafted the manuscript. MK Wong and H.C. Hu provided clinical guidance. W Tseng contributed to the manuscript revision, and H.Y. Cho and H.C. Hu were involved in the data analysis.

Corresponding author

Correspondence to Shih-Ying Chien

Ethics declarations

Ethics approval and consent to participate

The study obtained approval from the Research Ethics Committee for Human Subject Protection of Chang Gung Medical Foundation (IRB NO. 202200070B0). The authors affirm that all procedures were conducted in strict accordance with the pertinent guidelines and regulations, and an informed consent form was obtained and duly collected from all participants prior to commencing the study.

Consent for publication

Not applicable.

Competing Interests

The authors declare that they have no competing interests.

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No competing interests reported.

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Understanding Long-term Requirements in Pulmonary Rehabilitation for COPD: Insights from Interviews with Respiratory Care Professionals

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Abstract

Introduction

Method

Participants

Data collection

Data analysis

Results

Necessary Conditions for Clinical Pulmonary Rehabilitation

The Need for Assistive Devices in Pulmonary Rehabilitation

Post-Discharge Care for Patients with Chronic Lung Disease

Discussion

Conclusion

Declarations

References

Additional Declarations

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